Behcet’s disease
is a rare cause of genital ulceration. It is a chronic relapsing multisystem vasculitic disorder with unknown aetiology.
The diagnosis of Behcet’s disease is based on
clinical criteria and the International diagnostic criteria for Behcet’s disease include oral aphthosis,
skin manifestations, vascular lesions, pathergy
phenomenon, genital aphthosis, and ocular lesions (2

,3).
Our patient had fulfilled the criteria of recurrent oral and genital
ulcerations plus the cutaneous manifestation, and hence, a diagnosis of Behcet’s disease was made.

Genital ulcers of Behcet’s disease typically start as a
tender nodule, it will then become deep and painful, and
eventually heal with scarring. Searching for scars on genital skin, even in the
absence of active, clinical disease is an important part of the examination.
Ulcers typically are found on the labia majora, but
can occur anywhere on the vulva, perineum, or perianal skin. They can also
occur intra-vaginally, potentially leading to fistula formation with the
urethra or bladder.

Although
literatures have not studied on the effectiveness of colposcopy and biopsy in
the diagnosis of Behcet’s disease, colposcopy
definitely has a role in a more detailed evaluation of the genital tract,
characteristics of the ulcer and to rule out the possibility of malignancy.
There are also case reports and studies of people using colposcopy in aiding
them in the examination of genital ulcers in Behcet’s
disease.

Upon
biopsy taking, care
should be taken to obtain a full-thickness punch or incisional specimen that
includes skin from the periphery of the ulcer, rather than from the center of
the lesion.Histopathological results in Behcet’s
ulcer are
typically nonspecific with chronic active inflammation and necrosis without vasculitis as demonstrated in the above slides. Special
staining may be used to the biopsies to facilitate the diagnosis of specific
infection.

Papanicolaou smear in
our patient showed ASCUS, but she had a normal cervix on colposcopy and biopsy
results showed cervicitis only. In a prospective study by Suna
and collesgues looking at 152 women, of whom 78 are
patients with Behcet’s disease, it was noticed that
abnormal cervical cytology, acetowhite epithelium and
iodine-negative epithelium on colposcopy were more common in Behcet’s disease patients than the control. However, the
rate of abnormal histopathology was similar between both groups. The majority
of the ASCUS results revealed a normal finding after cervical histopathology in
patients with Behcet’s disease. This was postulated
to be caused by the benign inflammatory changes in the cervical epithelium (2).

In general, malignancy is rare in Behcet’s ulcers. In a recent case report by Hata and collesgues, a squamous
cell carcinoma in a chronic genital ulcer has been reported in a female patient
with Behcet’s disease (4). For these
reasons, it might be expected that the disease may lead to abnormal cervical or
vaginal epithelial changes. However, there is no study to confirm its causal
relationship yet (2).

As
demonstrated in this case, diagnosis for recurrent genital ulcers can be
difficult, however once the information of oral ulcer was obtained, the
differential diagnosis of Bechet’s became more
evident. Therefore, the
most important aspect of the evaluation of a patient with vulvar aphthae is a complete history and physical examination,
with particular attention to signs or symptoms of an underlying associated
systemic condition.